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of electronic health record (EHR) systems flowing to solo practitioners and small practices via the EHR Incentive Program, one would think the big vendors would be lining up to stake their claims in the frontier that is the ambulatory EHR market.

More on selecting ambulatory EHR software

In fact, some are: Allscripts-Misys Healthcare Solutions Inc., Greenway Medical Technologies Inc. and eClinicalWorks Inc. have had ambulatory EHR products on the market for years. General Electric Co. (GE) recently introduced a Software as a Service (SaaS) version of its Centricity system.

Epic Systems Corp., meanwhile, is an interesting case. There is little evidence that the Wisconsin EHR juggernaut is appealing directly to the solo physician, but sources tell SearchHealthIT.com that the company employs trainers for large hospitals, called affiliates, to resell Web-enabled Epic EHR installations to local doctors' offices, and to provide technical support as well.

Whatever the strategy, it is clear that large EHR vendors see value -- and opportunity -- in competing for the vast majority of physicians' offices that are not using ambulatory EHR software but must by 2015 to avoid reduced Medicare reimbursements. There's a lot that small offices should keep in mind when they consider what these large vendors have to offer.

SaaS EHR starting slow, but it could be the answer

SaaS-based EHR systems appeal to physicians for numerous reasons, chief among them accessibility, cost, and the ease with which products are upgraded and updated. Concerns about storing patient data off-site and trusting a third party to maintain uptime and access suggest nevertheless that physicians may not trust SaaS EHR at the moment, said John Moore, managing partner of Chilmark Research.

That will change, though, as the cost of moving from paper to electronic records becomes obvious and SaaS EHR systems prove to be less expensive to install, operate and maintain, Moore said.

"A lot of these physicians are relying on their nephew, their son or daughter to deal with these IT issues. They're not very effective or skilled, especially when they look at privacy concerns and HIPAA," Moore said, referring to the Health Insurance Portability and Accountability Act of 1996.

Dr. Jason Mitchell, assistant director of the American Academy of Family Physicians' Center for Health IT, said he understands physicians' fears of cloud storage. The usual reasons for patient data going off-site are that a lawyer is getting ammunition for a lawsuit or an insurance company is going over a record en route to denying a claim.

Mitchell's organization is encouraging its members to consider SaaS EHR systems, however. Data standards and interoperability initiatives from the Office of the National Coordinator for Health Information Technology (ONC) will help physicians change EHR vendors more nimbly if one doesn't work well -- something that hasn't been part of the EHR market for the last decade, he pointed out.

"Larger companies know they aren't going to sell their enterprise-type products and large servers into the smaller practices," Mitchell said. "They're hoping they can minimize costs by providing a single software platform provided on hosted servers . . . [to minimize] support costs to the practice and to the company, as well."

Predicting which ambulatory EHR products will win

Picking an EHR vendor from among the hundreds on the market can be daunting, especially to a physician already busy delivering health care. One criterion to avoid is the thought that a particular product will be the eventual market leader, Mitchell said. It is way too early to bank on any one vendor, he said, though it is possible that the first vendors to get meaningful use certified by ONC -- whether big or small -- could get a leg up on the rest.

If you don't have your clinic finances in order, an EHR is not going to save you.

Dr. Jason Mitchell, assistant director, American Academy of Family Physicians' Center for Health IT

Chilmark Research's Moore -- who recently pontificated on Microsoft pulling out of the EHR market -- points out that a smaller EHR vendor today could be huge tomorrow. Mergers and acquisitions almost certainly will take place, because there are too many EHR systems available and the market is ripe for consolidation, he said. The smaller vendors will be the first to go, while such large companies as the $17 billion GE will stick around longer, he added.

At the same time, smaller but more established ambulatory EHR vendors such as Greenway might be able to respond to a physician's needs more nimbly and withstand more market turmoil, Moore said. Practice Fusion Inc., which is backed by Salesforce.com Inc., is another company to watch. If Salesforce,com were to overlay a simple EHR system onto its popular SaaS sales tool, it could suddenly be a contender for market share, he said.

Solo physicians considering EHR options -- as well as the IT leaders supporting small group practices -- need to analyze their practice's workflow design before they start the vendor selection process, Moore said. They then should choose an ambulatory EHR system based on their needs, one with a feature set that matches what they need for data tracking, quality reporting and interacting with area hospitals.

The Center for Health IT's Mitchell concurred: "If you don't have your clinic finances in order, an EHR is not going to save you."

Providers also should read the fine print in vendor meaningful use guarantees and figure out exactly what is guaranteed. That a provider will get all $44,000 of the incentives? That all software upgrades for a set period will be meaningful use certified? That the vendor will meet usability requirements set by the National Institute of Standards and Technology? "Don't just chase the meaningful use dollars," Moore said. "Think longer term."

It pays to check out the integrators and support resources that come with a particular vendor, Moore said. For example, if a physician works with a local hospital that happens to be an Epic affiliate, getting on that hospital's Epic system might be the best choice, he suggested. But if an independent practitioner works with -- or at -- several hospitals, a different EHR application, interoperable with all those hospitals' EHR deployments, might be a better fit.

"Talk to your peers who may already be using the system," Moore said. "Support from any software vendor, in my experience, is very localized."

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